Sunday 4 May 2014

“Four problems”—a typical day for a GP

Judging from the expectations people often have of their appointment with a GP, there seem to be many misconceptions:
  1. Time is no object. Unfortunately, like anyone, GPs are paid per year for their own time, that of their staff and of their buildings and other expenses to meet the medical needs of a group of patients. In order meet these costs, they must have on their books perhaps 2000 patients. After setting aside time to visit the small number who are too frail safely to attend the surgery and further time for administration (writing referral letters, acting on test results and reports and managing repeat prescriptions), the vast majority of GPs find they must offer appointments in the surgery at 10 minute intervals. This has traditionally been sufficient for matters of average complexity, one at a time. Clearly, some patients will require a little longer; others should not feel short-changed if, having simpler medical needs, they get a little less time.
  2. Appointments are 10 minutes long. 10 minutes sounds short enough. However, 10 minutes is all your GP has to quickly familiarise himself with the history in your records, wait for you to reach his room and sit down and to make notes after the consultation. In reality, there will probably be no more than 7 minutes of face to face time.
  3. A caring GP runs late. Leaving aside for one moment whether it is right that your GP spends less time with his family if your appointment over-runs, the people that really pay are his other patients. If your appointment has ever started 30 minutes late, you will already have borne the cost of others' appointments lasting more than 7 minutes. Have you ever had a referral or report delayed? More examples of what public health physicians call "opportunity cost".
  4. Your GP has unlimited time outside of the consultation. If your GP had spare time, there is nothing most of them would like more than to offer longer and/or more appointments. The time between surgeries is barely enough for visits and administration, let alone attending meetings, writing "doctor's notes", undertaking email consultations or anything else, as we tried to explain to Health Minister Norman Lamb.
  5. The GP consultation is an ideal opportunity for new work. Because of a large proportion of the population pass through our doors, our consultations are seen by every special interest group as a unique opportunity to focus on what they consider to be most important for population health. As such, the Quality and Outcomes Framework of our 2004 contract made much of our pay dependent upon such additional activity, much of which would have been perceived by patients as detracting from that which they had actually made the appointment for. GPs are very well placed to do all manner of work, but it needs to be properly resourced, bearing in mind that some activity might be more appropriate for other sections.
  6. GPs are overpaid. It may surprise some to know that to become a GP one has to undertake a 5-6 year unpaid degree course and then a further 5 years of postgraduate training. The work is of an intensity which most cannot sustain for more than 4 days per week and is significantly stressful. As such, GPs are right to expect to be well remunerated. Clearly, it is largely a vocation and certainly it is a great privilege to share some of the more challenging moments of our patients' lives. However, with the current working conditions, many are tempted out of clinical medicine altogether or to work abroad.
    It could be argued that GPs could spend more time with each patient by having fewer patients on their list and therefore earn less. However, there are barely enough GPs for the current ratio; with expected retirements outstripping the training of whole-time equivalent GPs, GPs are likely to become even scarcer.

Medical need, Jonathon and Charlotte and #PutPatientsFirst

Admittedly, GPs are frequently consulted about matters for which medical treatments confer little or no benefit. However, in his BMJ blog this week,  describes the case of Charlotte, a woman with real and pressing medical needs, all of which he felt obliged to address during one appointment. It makes for compelling reading and illustrates many of the points I have made above. Note, for example, the effect of over-running on his subsequent patients.

Let us do some simple arithmetic. As established above, Charlotte and Jonathon had 7 minutes time scheduled together. Each one of Charlotte's problems could easily have done justice to a separate 7 minutes (taking up 40 minutes  - 4 x 10min of GP time). She needed a blood test (5 min) and a referral (5 min) and interpretation of the outcomes of these (5 min). So, for an appointment scheduled for 10 minutes, Charlotte took 35 minutes of Jonathon's time, when she really need an hour.

Charlotte's case illustrates very well how GPs scarcely have the time or resources to look after their patients at present. We are painfully aware that demand is rising (people are consulting us sooner in each illness, more often and for a wider range of conditions), we are being asked to do ever more work previously done by specialists, and politicians seem to think that all we need is more work. Couple that with the recruitment and retention crisis and we have a perfect storm in the making.

As the  campaign by the Royal College of General Practitioners asserts, General Practice urgently needs more resources to manage the status quo, let alone what is around the corner.


Unknown said...

This is why I have left the NHS and emigrated to Australia. I no longer felt that we were putting patients first. In fact one could argue that patients come a distinct 3rd or 4th after QOF, QIPP and CCG!
My experiences and reasons for leaving can be found here -

Unknown said...
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